EM Hema 3: Emergency Complications of Malignancy

Question 1

malignancies most commonly associated with hypercalcemi

Answer 1

breast CA
lung CA
multiple myeloma

Question 2

classic symptoms of hypecalcemia

Answer 2

lethargy
confusion
anorexia

others:
constipation
osmotic diuresis -> relative hypovolemia

Question 3

hypercalcemia does not always require treatment, especially if the patient is asymptomatic and well hydrated and the total serum calcium is

Answer 3

less than 14 mg/dL (3.5 mmol/L)

conversion factor: 0.25 (mg/dL -> mmol/L)

Question 4

how to hydrate patients with hypercalcemia

Answer 4

IF HYPOVOLEMIC:
1-2 L PNSS initial bolus over 1 hour

IF EUVOLEMIC:
250-500 mL/hour PNSS IV for 1L, followed by
100-150 mL/hour PNSS IV

Question 5

Role of furosemide in hypercalcemia

Answer 5

useful in patients with heart failure or renal insufficiency to prevent volume overload from NSS infusion,

but has little additive effect to the use of IV saine alone in those with normal cardiac and renal function

therefore, furosemide is NOT routinely recommended in tx of hypercalcemia due to malignancy

Question 6

remarks on bisphosphonates

Answer 6

pamidronate 60-90mg IV over 2-4 hours

zoledronic acid 4 mg IV over 15 mins

“bisphosphonates are the recommended agents to treat malignancy-associated hypercalcemia”

• potent inhibitors of bone resorption
• onset of actions may take days
• use with caution in renal insufficiency
• slow iV infusion to prevent precipitation of bisphosphonate-calcium complexes in the kidney and subsequent renal failure

Question 7

steroid-sensitive tumors

Answer 7

lymphoma
multiple myeloma

e.g. prednisone 60 mg PO daily

Question 8

MOA of denosumab

Answer 8

inhibits osteoclast activity and function

approved for hypercalcemia refractory to bisphosphonate therapy